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Over the next few months we will be featuring a number of spotlights on current rural GPs across Scotland. Dr Steve McCabe works at the Portree Medical Practice on the Isle of Skye and has written the following to give his perspective on rural healthcare…

Portree Harbour

Who am I?

My name is Steve McCabe. I have been involved in rural health for nearly 30 years. But I grew up in Airdrie, a town in Scotland’s industrial heartland and as a child I had no real connections to rural Scotland. The house I lived in stood on a hill. My bedroom was on the southwest corner of the house and it had two windows – one looking south, the other looking west. From the south window at night I could see the sky being “set alight” when the giant steel works at Ravenscraig opened their furnace doors. But from the west window on a clear day I could see the mountains of Arran.

Where am I?

I work as part of a group practice in Portree, the largest settlement on Scotland’s second largest island, Skye. Skye is widely regarded as one of the most beautiful islands in the world. It is one of the few Scottish islands with a growing population and Portree is the hub of island life, a busy wee place.

We also look after the islands of Raasay (pop. 192) and Rona (pop. 2).

The Wednesday commute to Raasay

Why am I here?

I was brought up on the stories of James Herriot (and his idyllic life as a rural vet) and A. J. Cronin’s heroic rural doctor, Dr Finlay. During school holidays my parents took me to rural areas – the East neuk of Fife, the Galloway hills, the Yorkshire dales. I knew from when I was 14 years old that I wanted to be a rural doctor. It is for this reason I went to medical school and nothing there changed my mind. While all my colleagues were jetting off to California or Queensland or Fiji for their electives I was living in an old dairy in the Scottish Borders experiencing rural GP life first hand. As a result I did my GP training in the Borders and subsequently worked as an Associate GP on Islay and Jura during 1995/96 before taking up my current partnership in Portree in May 1996.

Who is our population?

The island has three other practices but ours is by far the largest with 5500 patients – about half the island’s population. On top of that we are currently also dealing with about 1000 visitors each year but these are only a tiny fraction of Skye’s total number of visitors each year which now exceeds three quarters of a million people.

Who do I work with locally?

We have a full complement of primary care staff on the island (and a separate out-of-hours service) and we work very closely with all of them. Of course, just as with rural doctors, there is a fairly constant pressure on the recruitment and retention of community nurses, midwives and allied health professionals.

The Cuillin of Skye

What impact has the new GP contract negotiations had on me?

In its 2004 iteration the GP contract, negotiated at a UK level, had a very negative impact on rural practice in Scotland. It withdrew at a stroke many of the had-fought concessions rural practice had achieved. So, no more distant island allowances, no more rural mileage payments, no more notional lists, etc. Literally overnight we saw our income fall by more than 20% and we have never recovered that deficit.

I worked hard for nearly 17 years on BMA Scotland’s Scottish Council trying to highlight rural concerns and to rural proof BMA Scotland policy. I had hoped that, as a result, a new Scottish GP contract, negotiated in Scotland, would have had rural issues at its forefront. But instead we are told by BMA Scotland that rural is “too difficult to sort” and we have been kicked into a patch of long grass called phase 2.

RGPAS have been excellent at highlighting this iniquitous situation and we must give strength to their arm by supporting them as much and as often as we can.

What challenges do I face engaging in the political process?

None really – it is something I have always done throughout my professional life, driven as I am by a core belief that as GPs we have a fundamental role in local and national social activism. I have even managed to go so far as to have a debate on rural health issues held in the Scottish Parliament. I have over the years widely discussed rural health issues and concerns in national newspapers and on national radio and television. I continue to write a monthly article for a current affairs magazine in which I refuse to pull any punches.

What are my thoughts regarding the future?

I try to live in the moment as much as I can. I absolutely love my job and look forward to going to work every day. I miss it when I am on holiday. For me it has always been a vocational thing and that remains so now more than ever.

But the reality is I will be 53 later this year and I cannot go on for ever. I always said I would stop working as a doctor while I felt I was still at the top of my game rather than fizzle out and fade away. I can see already I don’t have the stamina I used to have and I am increasingly tired after busy days. My memory is also not as sharp as it was – the days of me never having a diary (which I didn’t until my mid-40s – I kept it all in my head and never missed anything) are now gone. So my plan is to retire at 58. One of the main driving forces behind that decision is that I will do my next revalidation at 54 and it will be my last. I regard revalidation as one of the worst things to happen to our profession and I am still sad to this day that we allowed it to be thrust upon us and that we let go of the wonderful model of appraisal we previously had.

And when I do retire I don’t know what I will do – but it will be something completely different…

Over the next few months we hope to feature a number of spotlights on current rural GPs across Scotland. Dr Martin Beastall works on Jura with his wife Dr Abby…

Life and Work on the Isles of Islay & Jura: Living the Remote and Rural Dream

Who are we?

Jura Medical Practice consists of a husband and wife GP team – myself (Dr Martin Beastall (42)) and Dr Abby Beastall (36). I am responsible for the running of the Surgery on Jura and Dr Abby works mainly at the Bowmore Surgery on Islay, and does one session per week on Jura. Between us, we are also responsible for out of hours care on Jura 24 hours per day, 7 days per week. We came to Jura just over 5 years ago having both worked in and around the Doncaster area in England for a similar length of time. We were both looking for a change, an adventure, and having both worked in large urban Practices, a chance to reconnect with our patients and make a real difference to their lives. We met on the Doncaster GP training scheme in 2005. I had changed from Surgical training, whereas Abby had always intended to train as a GP. Between us, we have a varied mix of skills, perfect for the challenges that Remote & Rural Medicine brings.

Where are we?

Jura is a large island of approximately 400 square kilometres in the Southern Hebrides, situated to the north east of Islay. Jura has a tiny population (under 250), whereas Islay’s community numbers just over 3000. We are situated directly west of Glasgow as the crow flies. An ill patient can be transported by helicopter to Glasgow in under 30 minutes, whereas a journey by car requires two ferries and takes most of a day to complete.

Why are you there?

Rural General practice brings with it many challenges but also great rewards. We have the opportunity to genuinely provide ‘cradle to grave’ medical care and to be an integral part of our patients’ lives. We are a small but thriving community on Jura. We believe having medical services here is essential for the continued growth and stability of our community and that without continuity and stability, the future of the community overall would be threatened.

Who is our patient population?

The population of Jura matches the overall Scottish demographic, just in miniature. Every age group is represented and the care we provide ranges from baby vaccinations to very personal palliative care for those coming to the end of their lives.

Who do you work with locally?

Being the GP on Jura means being the Doctor, Practice Nurse, Phlebotomist, Health Care Assistant, Paramedic and Pre-Hospital Responder all in one. Flexibility and a willingness to attempt almost any task asked of you is key here. We are lucky to have a dedicated team of carers and District Nurses on the island, and are well supported by allied health professionals based on Islay also. Emergencies are dealt with locally when possible, but a comprehensive support structure exists regionally to provide help ranging from helicopter transport to full blown medical retrieval teams when required.

What is it like having 24 hour a day responsibility for your patients’ health and wellbeing?

Being ready and available 24/7 can be hard psychologically. Patients have direct access to their GP here (rather than using a service such as NHS24) which has its pros and cons. Being able to deal with things locally is very satisfying but it can be hard sometimes to demonstrate to the wider world the time and money saved by avoiding transferring patients elsewhere.

What impact have the new GP contract negotiations had on you?

We have both been very grateful for the efforts made by the RGPAS on our behalf. We feel that as rural GPs we are very much an afterthought. Issues such as the provision of out of hours cover after April 1st 2018 have been very unclear. This has had a destabilising effect on us, exactly the opposite of the stated intended effect of the new contract.

What challenges do you face engaging in the political process?

Being geographically remote and (due to childcare issues) essentially single handed means attending meetings is very difficult given the 24/7 responsibility for patient care. Video conferencing and webcasting still seems the exception rather than the norm. It is easy to feel out on a limb here.

What are your thoughts regarding your future?

We both remain positive about our futures living on Islay and Jura. We cannot imagine a better community to live in and raise our daughter in, and are hopeful that the new GP contract will enable us to continue to provide the high level of medical care we have done for the last five years for the foreseeable future.

Today marks the start of the 14th WONCA World Rural Health Conference, being held in Cairns, Australia.

The programme is set to contain a fantastically diverse range of research and workshops covering everything from improvements in patient care, to developing new and effective ways to collaborate across boundaries in rural health. You can follow the events on twitter using the #RuralWonca hashtag, and already there has been a huge number of comment and links

So far, the vibe at #RuralWonca has been great… benefitting from Cairns hospitality (boosted by a dynamic and helpful team from ACRRM) and a stimulating range of input from stalwart experts in rural medicine, to young, enthusiastic students and young doctors.

Thursday saw a full day of proceedings for the WONCA World Working Party for Rural Health – with the annual Council meeting held in spectacular surroundings of a seminar room looking directly onto rainforest. As well as hearing about events from the last year, and sorting out logistics for yet another busy year ahead, there was debate about how best to support member organisations and do everything possible to support the growing number of student and young doctor organisations. The highlight of 2018 is set to be the 15th World Rural Health Conference. Crumbs, we haven’t even started the 14th conference yet, but for a taster of what’s in store – in New Delhi – see the video below!

Friday brought the World Summit on Rural Generalist Medicine. The concept and importance of rural generalism in health ecosystems is reaching high levels of resonance now within Australia (where political support for recognising this is higher than ever), and much further afield in both ‘developed’ and ‘developing’ nations. It is clear that empowering rural generalism within healthcare systems has never been more important, with absolute needs to train future doctors in medical complexity, meet the demands of an ageing population and achieve the levels of health service efficiency that are often more easy to find in the generalist setting.

The Summit also saw the launch of the Japanese Rural Generalist Programme: a major achievement and indicative of the direction that other countries are likely to go too, not least through the inspiration that these developments bring.

You can follow tweets from the Summit meeting using the hashtag #RuralGeneralist

And now for the main event. This looks set to be a stimulating and busy few days ahead, bringing together an enthusiastic and dedicated group of international confreres giving the opportunity to recognise and drive forward international innovation and collaboration in rural health. We hope to feature a number of interviews and reports on RuralGP.com over the next few days, like we did with the last conference in Dubrovnik, between a very packed and interesting programme of events.

Check the end of this article for tweets and images that have been posted online since the hashtag went live… and you can also now view most of the photos from the #ruralGPframed series at gallery.ruralGP.com too

Image from W Eugene Smith’s “A Country Doctor”. LIFE Magazine, 1948.

the best camera is the one you have with you

1948 saw the beginning of the National Health Service in the UK. Many of its principles were based on the development of the Highlands & Islands (Scotland) Medical Service which was launched in 1913 following the publication of the Dewar Report into the challenges of rural healthcare in Scotland – and many consider the Dewar Report to be the blueprint of today’s NHS.

Since then, photography and photojournalism has evolved significantly. Nearly everyone now has a quality camera-phone in their pocket. The development of digital photography has resulted in the limits of photography being confined only to battery power, memory card space, and creativity.

And yet, some would argue that this has had the effect of devaluing the art of good photography. Paradoxically, because photography is within such easy reach, we sometimes fail to document episodes of experience – either as we assume someone else will be, or the immediacy of image capture devalues the art of composition, style and creative depiction. And because so many images are produced (Facebook estimates that over 300 million photos are uploaded to its website every day), it is likely that great images fail to get the recognition and prominence that they deserve.

In just over a month’s time, I will be running a ‘Practical Tips’ session at the Rural WONCA conference in Cairns, Australia – on The Visible Rural GP: developing an image bank for modern rural practice. The idea for this evolved through a personal interest in photography and its journalistic role, an interest in ‘how do we represent rural practice to potential rural GPs’ and awareness of projects such as Document Scotland – just one inspirational project that aims to “photograph the important and diverse stories within Scotland at one of the most important times in our nation’s history”.

A tick that I removed from a patient who presented to our Arran War Memorial Hospital one summer weekend oncall. (Assumed consent from tick). Canon 60D, with reversed 50mm; August 2016.

Perhaps we should be considering the need for presenting inspiring, accurate visual representations of rural practice today.

And so today, in the run-up to Rural WONCA 2017, I am committing to share (via Twitter, using the hashtag #RuralGPframed) at least one photo per day, from my own images, that depicts an aspect of rural practice.

I would be delighted for others to join me. The more images that we can collect and share, to represent the stimulation, challenge and professional satisfaction of rural practice, the more insight that others – including potential rural GPs – will have into the opportunities that rural practice can offer.

Dr Kate Dawson (GP, Benbecula) and Dr Charlie Siderfin (GP, Orkney) during a valuable opportunity to get together and discuss research opportunities in rural practice. Fujifilm XT1; January 2017.

What about video?

‘A picture is worth a thousand words’ but video often allows a narrative and mood to be more easily captured. Video is important, and submissions of video are welcomed to this project.

Please remember, explicit consent is required for any footage featuring patients or anything related to them. Creativity is welcomed!

4/4/17 Update

Within 24 hours of this post going live, we’ve had an amazing amount of coverage across the world, particularly our Australian confreres. Keep them coming! Here’s just a few of the tweets that we’ve picked up on the hashtag…

Fittingly, this is the 200th post to appear on RuralGP.com. And with this comes the welcome news that interest in the site has never been so high, with groups including RPAS and the Dewar 2012 Centenary opting to have their sites hosted here too.

Updated design

It makes sense. RuralGP.com has been attracting over 5,000 visits per month for a sustained period now. The site has grown into a useful resource (and timeline) for rural practice over the last few years, and its development has allowed it to keep up to date with advances in web design and technology. We recently updated the site to a new WordPress theme called ‘Canvas’ – which gets excellent reviews and which has already allowed some subtle, but important changes in function.

Just a quick word on that… if you are an Internet Explorer 6 or 7 user, you may not see the site properly… this is a universal problem with responsive design, which works better for most other web browsers, including from smartphones. If you’re not able to see columns of information, and the site looks a bit bland – please consider upgrading as this will be affecting other sites that you view too. Meantime, we hope that you have been able to see the benefits from other browsers that you use.

New home

At the recent AGM of the Remote Practitioners’ Association of Scotland, it was very positive to learn that RPAS wishes to support some of the background costs of maintaining RuralGP.com connectivity – and this has allowed us to switch to our own server, hosted by the helpful folks at 34sp.com. You may have already noticed a great improvement in speed and reliability of the site, and that’s thanks to a commitment from RPAS to support some of the costs in this move.

Where next?

RuralGP.com remains an independent resource and welcomes any input from budding bloggers or authors. It is very easy to set up new author accounts, allowing anyone to write and illustrate an article, and submit it for publishing on the site. If this appeals to or interests you, please do get in touch. For a number of years we have also hosted free advertising of jobs, and this is set to continue.

We hope to develop some other materials too. It’s becoming ever easier to develop video and audio streams, and we hope to do that here more frequently. With the move to a faster server, it’s even more possible to harness this sort of technology. Edited by a practising rural GP, it should be fairly easy to suss out some of the more relevant and priority topics that would be worth covering: a lot depends on time available. Recent efforts have been to focus on recruitment and professional isolation, by engaging with students and trainees, and utilising the RuralGPNetwork email list.

So, thanks to RPAS for committing their support for the site, and thanks to our other supports of RuralGP.com.

Enthused? Inspired? Get in touch with the RuralGP.com editor using this form…

Many thanks to everyone who took part in the mentoring survey, which closed tonight after 2 weeks. This was kindly hosted by RCGP. Over fifty rural medical practitioners responded, with some useful and insightful results.

The raw data are presented below. If you can’t see anything, you can also download a PDF file here. Apologies that this is slightly clunky – and please note that comments are presented at the end of the PDF. If you have a large screen, it may be worthwhile opening up two windows so you can follow the questions and free text answers at the same time.

Further analysis will be carried out to summarise the main conclusions. It is hoped to present this on RuralGP.com in the next few weeks. In the meantime, I have made the following observations on what could be considered the ‘next steps’:

Development of a profiles page, giving details of rural GPs who are prepared to act as mentors for committed trainees. (With some time for thought about how this should be co-ordinated and supported).

Development of a scholarship scheme for medical student electives.

Play down the role of social media, and improve quality student/trainee access to good rural practice experience.

Discussion can take place via the various email groups, or post a comment below.

RuralGP.com has been going from strength to strength as a recognised resource by rural GPs for rural GPs. It aims to highlight some of the key stories and events of interest to rural practitioners across the UK and beyond. Being consistently in the top results for a Google Search of “rural gp”, “rural practice”, “remote and rural” and “rural medicine”, it has an ever-increasing chance of being visited by students, trainees and current rural GPs seeking opportunities for work and networking.

How do we know if we’re getting it right?

One resource is the statistics machine that sits in the background, monitoring website activity. Despite picking up some automatic searches by robots, the figures for the site show an increasing trend of activity. RuralGP is attracting over 150 visits per day, equating to 5000+ visits per month. We can see that the site is visited via links from external sites, and monitor the difference that articles such as this one in Pulse make to our viewing rate.

Remember, RuralGP.com is a free resource, run voluntarily and open to any offers of articles or editorship. In addition, we are happy to feature:

your job advert, free of charge

local service design, that may be of interest to other rural practitioners

training issues, or advice for future rural GPs

links to useful videos, podcasts and stories

your ideas to make the site more relevant, accurate and engaging

The latest statistics are displayed in the images below. Note that May is incomplete data – based on 4 days of data.

Today RuralGP launches an email group specifically targeted at rural GPs working in community hospitals:

Providing cover to community and rural hospitals is something that many rural GPs have done since general practice began. A plethora of models has developed, each tailored to their local community’s needs and ranging from small units for convalescence, to large diagnostic facilities capable of advanced medical care.

The aim of RuralGP@Hospital is to allow good practice to be shared and specific challenges to be considered by a forum of similarly-minded GPs. With revalidation set to begin soon, and the inevitable focus that this will bring on accredited clinical governance, we hope that this network will help to ensure that rural hospital GPs have access to a responsive source of advice. Similar challenges are being faced by our international colleagues, such as in New Zealand, and it is hoped that they will join in the advice and debate.

It’s free to join, and easy to sign-up. As it’s email based, you can easily set up a filter if your inbox is already bulging. We’ll run this as a pilot over the next 6 months, and continue it indefinitely if it proves to be useful. We have sought advice from organisations including the Scottish Association for Community Hospitals, who agree that this could prove to be useful resource.

Today we launch the new, rejuvenated site of RuralGP, now hosted here at RuralGP.com. Take a look around to see what’s changed, and as always, feel free to feed back your comments.

The main improvements are:

a cleaner, more functional appearance.

more use of static pages for information on careers advice, links to other networks etc.

we now host this site ourselves, which should result in speedier pages and more flexibility. It should now be easier to access the site from all computers, including those behind overzealous firewalls.

Following this redesign, work will continue on improving and updating the information available on this site, with particular attention to relevant e-Learning resources, and providing advice to students and trainees about career opportunities in rural practice. Help with this would be gratefully received. If interested please contact us.